Positive Outliers: A Mixed Methods Study of Resiliency to Childhood Obesity in High-Risk Neighborhoods.

OBJECTIVE: Despite the high prevalence of obesity and the clustering of risk by neighborhood, few studies have examined characteristics which promote healthy child weight in neighborhoods with high obesity risk. We aimed to identify protective factors for children living in neighborhoods with high obesity risk. METHODS: We identified neighborhoods with high obesity risk using geolocated electronic health record data with measured body mass index (BMI) from well-child visits (2012-2017). We then recruited caregivers with children aged 5 to 13 years who lived in census tracts with mean child BMI percentile ≥72 (February 2020-August 2021). We used sequential mixed methods (quantitative surveys, qualitative interviews) to compare individual, interpersonal, and perceived neighborhood factors among families with children at a healthy weight (positive outliers [PO]) versus families with ≥1 child with overweight or obesity (controls). Regression models and comparative qualitative analysis were used to identify protective characteristics. RESULTS: Seventy-three caregivers participated in the quantitative phase (41% PO; 34% preferred Spanish) and twenty in the qualitative phase (50% PO; 50% preferred Spanish). The frequency of healthy caregiver behaviors was associated with being a PO (Family Health Behavior Scale Parent Score adjusted ß 3.67; 95% CI 0.52-6.81 and qualitative data). Protective factors also included caregivers' ability to minimize the negative health influences of family members and adhere to family routines. CONCLUSIONS: There were few differences between PO and control families. Support for caregiver healthy habits and adherence to healthy family routines emerged as opportunities for childhood obesity prevention in neighborhoods with high obesity risk.

A Structured Home Health and Hospice Clinical Rotation and Onboarding Model to Address the Nursing Shortage.

North Carolina home health and hospice agencies are experiencing serious shortages of registered nurses (RNs), particularly in rural areas. These shortages can negatively impact patients and families by delaying access to care and possibly resulting in avoidable hospitalizations/rehospitalizations. Many home health and hospice agencies do not hire newly graduated RNs due to limited patient care experience, limited or no opportunity for home health/hospice clinical rotations, and the autonomous nature of providing care in the home. The Hospice and Home Health Foundation of North Carolina was awarded a $468,196 3-year grant, and, in collaboration with key stakeholders, developed a model for clinical rotation experiences in home health and hospice settings for RN students as well as an onboarding model for newly graduated RNs. Seven home health and hospice project partner agencies were selected to pilot the models. This article describes program implementation and evaluation. We used a survey method and site visit interviews to assess program effectiveness. Students provided positive feedback about the clinical rotation and more than 80% indicated their clinical rotation met "most" or "almost all" of their learning needs. The focus group interviews provided substantive anecdotal examples to validate the survey results.

Precision Medicine in Veterinary Science.

Precision medicine focuses on the clinical management of the individual patient, not on population-based findings. Successes from human precision medicine inform veterinary oncology. Early evidence of success for canines shows how precision medicine can be integrated into practice. Decreasing genomic profiling costs will allow increased utilization and subsequent improvement of knowledge base from which to make better informed decisions. Utility of precision medicine in canine oncology will only increase for improved cancer characterization, enhanced therapy selection, and overall more successful management of canine cancer. As such, practitioners are called to interpret and leverage precision medicine reports for their patients.

Dog size and patterns of disease history across the canine age spectrum: Results from the Dog Aging Project.

Age in dogs is associated with the risk of many diseases, and canine size is a major factor in that risk. However, the size patterns are complex. While small size dogs tend to live longer, some diseases are more prevalent among small dogs. In this study we seek to quantify how the pattern of disease history varies across the spectrum of dog size, dog age, and their interaction. Utilizing owner-reported data on disease history from a substantial number of companion dogs enrolled in the Dog Aging Project, we investigate how body size, as measured by weight, associates with the lifetime prevalence of a reported condition and its pattern across age for various disease categories. We found significant positive associations between dog size and the lifetime prevalence of skin, bone/orthopedic, gastrointestinal, ear/nose/throat, cancer/tumor, brain/neurologic, endocrine, and infectious diseases. Similarly, dog size was negatively associated with lifetime prevalence of ocular, cardiac, liver/pancreas, and respiratory disease categories. Kidney/urinary disease prevalence did not vary by size. We also found that the association between age and lifetime disease prevalence varied by dog size for many conditions including ocular, cardiac, orthopedic, ear/nose/throat, and cancer. Controlling for sex, purebred vs. mixed-breed status, and geographic region made little difference in all disease categories we studied. Our results align with the reduced lifespan in larger dogs for most of the disease categories and suggest potential avenues for further examination.

Interfacility Transfer Outcomes Among Children With Complex Chronic Conditions: Associations Between Patient-Level and Hospital-Level Factors and Transfer Outcomes.

OBJECTIVES: Determine patient- and referring hospital-level predictors of transfer outcomes among children with 1 or more complex chronic conditions (CCCs) transferred to a large academic medical center. METHODS: We conducted a retrospective chart review of 2063 pediatric inpatient admissions from 2017 to 2019 with at least 1 CCC defined by International Classification of Diseases, Tenth Revision codes. Charts were excluded if patients were admitted via any route other than transfer from a referring hospital's emergency department or inpatient ward. Patient-level factors were race/ethnicity, payer, and area median income. Hospital-level factors included the clinician type initiating transfer and whether the referring-hospital had an inpatient pediatric ward. Transfer outcomes were rapid response within 24 hours of admission, Pediatric Early Warning Score at admission, and hours to arrival. Regression analyses adjusted for age were used to determine association between patient- and hospital-level predictors with transfer outcomes. RESULTS: There were no significant associations between patient-level predictors and transfer outcomes. Hospital-level adjusted analyses indicated that transfers from hospitals without inpatient pediatrics wards had lower odds of ICU admission during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.97) and shorter transfer times (ß-coefficient, -2.54; 95% CI, -3.60 to -1.49) versus transfers from hospitals with inpatient pediatrics wards. There were no significant associations between clinician type and transfer outcomes. CONCLUSIONS: For pediatric patients with CCCs, patient-level predictors were not associated with clinical outcomes. Transfers from hospitals without inpatient pediatric wards were less likely to require ICU admission and had shorter interfacility transfer times compared with those from hospitals with inpatient pediatrics wards.

Impact of multidisciplinary team meetings on the management of patients with breast cancer in a large private healthcare facility.

AIMS: Multidisciplinary meetings (MDMs) play a crucial role in decision-making in breast cancer patient care. This study aimed to firstly assess the impact of breast cancer MDMs in decision-making for breast cancer patients and secondly to determine the concordance between MDM recommendations and implementation of clinical practice. METHODS: Patient cases to be presented at the weekly breast cancer MDMs were identified and prospectively enrolled. Management plans were predicted by the treating surgeon with the pre-MDM management plans then compared to MDM recommendations. Changes in decision-making were assessed in the following domains: further surgery, systemic therapy (endocrine, chemotherapy or targeted), radiotherapy, enrolment in a clinical trial, further investigations, and referral to other specialists or services. Patient records were subsequently reviewed at 3 months post-MDM to assess the rate of implementation of MDM recommendations and any reasons for discordance. RESULTS: Out of 50 cases, 66% (CI 53-79%; p < .005) experienced a change in management plan as a result of MDM discussion, with a total of 66 episodes of recorded change per decision-making domain affecting the following: further surgery (7.6%), endocrine therapy (4.5%), chemotherapy (19.7%), targeted therapy (4.5%), radiotherapy (18.2%), enrolment for a clinical trial (12.1%), additional investigations (22.7%), and further referrals (10.6%). MDM recommendations were implemented in 83.7% of cases. CONCLUSION: The breast cancer MDMs were found to substantially impact on the management plans for breast cancer patients, with 83.7% of MDM recommendations being implemented into clinical practice. This study reinforces the importance of MDMs in the management of these patients, as well as highlighting the need for further investigating and addressing the potential barriers to the implementation of MDM recommendations.

The Built Environment and Pediatric Health.

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health care professionals' care for patients and advocacy on their behalf. This policy statement outlines community design solutions that can improve pediatric physical and mental health, and improve health equity. It describes opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families. The accompanying technical report reviews the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities.

The Built Environment and Pediatric Health.

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health professionals' care for patients and advocacy on their behalf. This technical report describes the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities. The accompanying policy statement outlines community design solutions that can improve pediatric health and health equity, including opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families.

Feeding, television, and sleep behaviors at one year of age in a diverse sample.

Background: Healthy lifestyle behaviors that can prevent adverse health outcomes, including obesity, are formed in early childhood. This study describes feeding, television, and sleep behaviors among one-year-old infants and examines differences by sociodemographic factors. Methods: Caregivers of one-year-olds presenting for well care at two clinics, control sites for the Greenlight Study, were queried about feeding, television time, and sleep. Adjusted associations between sociodemographic factors and behaviors were performed by modified Poisson (binary), multinomial logistic (multi-category), or linear (continuous) regression models. Results: Of 235 one-year-olds enrolled, 81% had Medicaid, and 45% were Hispanic, 36% non-Hispanic Black, 19% non-Hispanic White. Common behaviors included 20% exclusive bottle use, 32% put to bed with bottle, mean daily juice intake of 4.1 ± 4.6 ounces, and active television time 45 ± 73 min. In adjusted analyses compared to Hispanic caregivers, non-Hispanic Black caregivers were less likely to report exclusive bottle use (odds ratio: 0.11, 95% confidence interval [CI] 0.03-0.39), reported 2.4 ounces more juice (95% CI 1.0-3.9), 124 min more passive television time (95% CI 60-188), and 37 min more active television time (95% CI 10-64). Increased caregiver education and higher income were associated with 0.4 (95% CI 0.13-0.66) and 0.3 (95% CI 0.06-0.55) more servings of fruits and vegetables per day, respectively. Conclusion: In a diverse sample of one-year-olds, caregivers reported few protective behaviors that reduce the risk for adverse health outcomes including obesity. Differences in behavior by race/ethnicity, income, and education can inform future interventions and policies. Future interventions should strive to create culturally effective messaging to address common adverse health behaviors.

Psychiatric mental health nurse practitioner student knowledge and perceptions of pharmacogenetic testing.

Psychotropic medications are typically prescribed in a trial-and-error fashion, and some providers are beginning to utilize pharmacogenetic testing (PGx) as a supplemental prescribing tool in treatment decision making. PGx testing shows potential in enhancing provider insights into personalized prescribing for patients by examining genetic information related to drug metabolism. Literature points to providers' lack of knowledge in PGx interpretation as a main barrier, including psychiatric mental health nurse practitioners (PMHNPs). The aim of this study was to measure a difference, if any, in the knowledge and perceptions of PGx after implementation using a pre-post design. This study implemented an educational intervention on graduate nursing students (n = 15). Data were collected by using a pre- and post-interventional questionnaire. Results demonstrated a significant difference in findings related to students' knowledge (p < 0.001), students' skills related to pharmacogenetics, (p < 0.001), as well as students' perceived ability to implement pharmacogenetics into their practice, (p = 0.028). The authors propose that the knowledge gained from the study demonstrates the importance of introducing PGx education into the PMHNP curricula and to prepare future PMHNPs to confidently utilize PGx in their clinical practice.

Identification of genomic alterations with clinical impact in canine splenic hemangiosarcoma.

Canine hemangiosarcoma (HSA) is an aggressive cancer of endothelial cells with short survival times. Understanding the genomic landscape of HSA may aid in developing therapeutic strategies for dogs and may also inform therapies for the rare and aggressive human cancer angiosarcoma. The objectives of this study were to build a framework for leveraging real-world genomic and clinical data that could provide the foundation for precision medicine in veterinary oncology, and to determine the relationships between genomic and clinical features in canine splenic HSA. One hundred and nine dogs with primary splenic HSA treated by splenectomy that had tumour sequencing via the FidoCure® Precision Medicine Platform targeted sequencing panel were enrolled. Patient signalment, weight, metastasis at diagnosis and overall survival time were retrospectively evaluated. The incidence of genomic alterations in individual genes and their relationship to patient variables including outcome were assessed. Somatic mutations in TP53 (n = 44), NRAS (n = 20) and PIK3CA (n = 19) were most common. Survival was associated with presence of metastases at diagnosis and germline variants in SETD2 and NOTCH1. Age at diagnosis was associated with somatic NRAS mutations and breed. TP53 and PIK3CA somatic mutations were found in larger dogs, while germline SETD2 variants were found in smaller dogs. We identified both somatic mutations and germline variants associated with clinical variables including age, breed and overall survival. These genetic changes may be useful prognostic factors and provide insight into the genomic landscape of hemangiosarcoma.

Shared hotspot mutations in oncogenes position dogs as an unparalleled comparative model for precision therapeutics.

Naturally occurring canine cancers have remarkable similarities to their human counterparts. To better understand these similarities, we investigated 671 client-owned dogs from 96 breeds with 23 common tumor types, including those whose mutation profile are unknown (anal sac carcinoma and neuroendocrine carcinoma) or understudied (thyroid carcinoma, soft tissue sarcoma and hepatocellular carcinoma). We discovered mutations in 50 well-established oncogenes and tumor suppressors, and compared them to those reported in human cancers. As in human cancer, TP53 is the most commonly mutated gene, detected in 22.5% of canine tumors overall. Canine tumors share mutational hotspots with human tumors in oncogenes including PIK3CA, KRAS, NRAS, BRAF, KIT and EGFR. Hotspot mutations with significant association to tumor type include NRAS G61R and PIK3CA H1047R in hemangiosarcoma, ERBB2 V659E in pulmonary carcinoma, and BRAF V588E (equivalent of V600E in humans) in urothelial carcinoma. Our findings better position canines as a translational model of human cancer to investigate a wide spectrum of targeted therapies.

Health-Related Quality of Life Instruments for Clinical Trials in AL Amyloidosis: Report from the Amyloidosis Forum HRQOL Working Group.

Systemic AL (light chain) amyloidosis is a rare protein misfolding disorder associated with plasma cell dyscrasia affecting various organs leading to organ dysfunction and failure. The Amyloidosis Forum is a public-private partnership between the Amyloidosis Research Consortium and the US Food and Drug Administration Center for Drug Evaluation and Research with the goal of accelerating the development of effective treatments for AL amyloidosis. In recognition of this goal, 6 individual working groups were formed to identify and/or provide recommendations related to various aspects of patient-relevant clinical trial endpoints. This review summarizes the methods, findings, and recommendations of the Health-Related Quality of Life (HRQOL) Working Group. The HRQOL Working Group sought to identify existing patient-reported outcome (PRO) assessments of HRQOL for use in clinical trials and practice deemed relevant across a broad spectrum of patients with AL amyloidosis. A systematic review of the AL amyloidosis literature identified 1) additional signs/symptoms not currently part of an existing conceptual model, and 2) relevant PRO instruments used to measure HRQOL. The Working Group mapped content from each identified instrument to areas of impact in the conceptual model to determine which instrument(s) provide coverage of relevant concepts. The SF-36v2® Health Survey (SF-36v2; QualityMetric Incorporated, LLC) and Patient-Reported Outcomes Measurement Information System-29 Profile (PROMIS-29; HealthMeasures) were identified as instruments relevant to patients with AL amyloidosis. Existing evidence of reliability and validity was evaluated with a recommendation for future work focused on estimating clinically meaningful within-patient change thresholds for these instruments. For sponsors, the context of use-including specific research objectives, trial population, and investigational product under study-should inherently drive selection of the appropriate PRO instrument and endpoint definitions to detect meaningful change and enable patient-focused drug development.

Novel Custom Maxillary Disimpaction Splint.

LeFort I, II, and III osteotomies are commonly used in complex craniofacial reconstruction. Patients requiring these procedures typically have a craniofacial cleft, other congenital craniofacial deformities, or severe facial trauma. Both the cleft and traumatized palate have poor bony support, which leads to possible complications when the disimpaction forceps are used during the downfracture of the maxilla. Such potential complications include trauma or formation of a fistula of the palatal, oral, or nasal mucosa; trauma to adjacent teeth; and fracture of the palate and alveolar bone. To help prevent these complications, we developed a custom disimpaction splint. The splint is designed to cover the palate and occlusal surfaces to increase retention and minimize splint movement during the maxillary downfracture portion of the surgical procedure. The base of the splint is fabricated from a two-layered biocryl material, and the palatal area is built with soft-cushion rebase material. This allows for a stable grip of the disimpaction forceps blades and provides protective coverage of the cleft, traumatized palate, or alveolar bone graft site during the downfracture. The custom maxillary disimpaction splint has been routinely used in our clinic from September 2019 to the present for LeFort osteotomies in patients with a compromised primary palate. No surgical complications related to the maxillary downfracture have been noted during this period of time. We conclude that the routine use of a custom maxillary disimpaction splint can result in improved outcomes and decreased complications of LeFort osteotomy procedures in patients with cleft and traumatized palate.

A Cross-Sectional Survey of Pediatric Infectious Disease Physicians' Approach to Congenital Cytomegalovirus Infection.

Congenital cytomegalovirus (cCMV) continues to be a major public health care issue due to its high prevalence throughout the world. However, there is a paucity of studies evaluating how providers manage this infection. This study surveyed North American Pediatric Infectious Disease (PID) physicians to elicit their approach towards the evaluation and treatment of this condition. Thirty-two PID physicians responded to this survey. Institutional testing and screening for cCMV were infrequently reported. The respondents in general agreed upon most laboratory and diagnostic testing except for neuroimaging. For those tests, there was a disparity in indications for head ultrasound versus brain MRI imaging. Most (68.8%) agreed with the clinical practice of starting valganciclovir in an infant less than 1 month of age with one sign or symptom of disease, and 62.5% would do so for an infant with isolated sensorineural hearing loss. However, only 28.1% would treat cCMV-infected infants older than 1 month of age. In conclusion, few healthcare institutions represented by PID physicians in this cohort had a cCMV screening or testing initiative, yet most respondents would test at a much higher level based on their clinical practice. While there is general consensus in evaluation and treatment of these children, there are disparities in practices regarding neuroimaging and indications for antiviral treatment with respect to age and severity of disease. There is a great need for an evidence based policy statement to standardize cCMV workup and treatment.

Unmet needs with antipsychotic treatment in schizophrenia and bipolar I disorder: patient perspectives from qualitative focus groups.

BACKGROUND: Schizophrenia (SZ) and bipolar I disorder (BD-I) are chronic mental health disorders often treated with antipsychotic medications. This qualitative study sought to better understand disease burden and treatment experiences with oral antipsychotic medications in participants living with SZ or BD-I. METHODS: Six 90-min focus groups were conducted with participants diagnosed with SZ or BD-I. Trained moderators facilitated discussions using a semistructured guide. Participants described symptoms, impacts of disease, and experiences with oral antipsychotic medications, whether favourable or unfavourable. RESULTS: Among participants with SZ (n = 15; 3 groups, 5 per group), 53% were male and 33% were white, with a mean of 18.6 years since diagnosis. Of participants with BD-I (n = 24; 3 groups, 8 per group), 33% were male and 42% were white, with a mean of 13.0 years since diagnosis. Participants described numerous symptoms of their illnesses that impacted relationships and daily life, including effects on emotional health, the ability to work, and encounters with law enforcement. Previous antipsychotic medications were deemed effective by 14/15 (93%) participants with SZ and 12/16 (75%) participants with BD-I. Most participants with SZ (13/15; 87%) or with BD-I (16/24; 67%) reported discontinuing their antipsychotic medication at some point. Side effects were a common reason for discontinuing or switching medications for participants with SZ (8/15; 53%) and for those with BD-I (11/24; 46%). The most common side effects reported in both cohorts were weight gain, drowsiness, sexual problems, and neurologic symptoms. Side effects negatively affected quality of life, leading to serious health problems and issues with self-esteem. CONCLUSIONS: People living with SZ or BD-I cited a range of favourable and unfavourable experiences with oral antipsychotic medications. Most participants reported that their antipsychotics were effective at controlling their symptoms, but multiple side effects impacted their quality of life, caused additional serious health problems, and often led to discontinuation of or switching antipsychotics. Findings from this study contribute to a better understanding of patients' experiences with antipsychotics and highlight a need for new medications with favourable benefit/risk profiles.

Regional variances depict a unique glial-specific inflammatory response following closed-head injury.

Mild traumatic brain injuries (mTBI) constitute a significant health concern with clinical symptoms ranging from headaches to cognitive deficits. Despite the myriad of symptoms commonly reported following this injury, there is still a lack of knowledge on the various pathophysiological changes that occur. Preclinical studies are at the forefront of discovery delineating the changes that occur within this heterogeneous injury, with the emergence of translational models such as closed-head impact models allowing for further exploration of this injury mechanism. In the current study, male rats were subjected to a closed-head controlled cortical impact (cCCI), producing a concussion (mTBI). The pathological effects of this injury were then evaluated using immunoflourescence seven days following. The results exhibited a unique glial-specific inflammatory response, with both the ipsilateral and contralateral sides of the cortex and hippocampus showing pathological changes following impact. Overall these findings are consistent with glial changes reported following concussions and may contribute to subsequent symptoms.

Organizational trust, usability, and inclusivity are key implementation facilitators for a proposed assets-based mobile health intervention.

Assets-based interventions can address child health disparities by connecting families to existing community resources. Community collaboration when designing interventions may identify barriers and facilitators to implementation. The objective of this study was to identify crucial implementation considerations during the design phase of an asset-based intervention to address disparities in childhood obesity, Assets for Health. We conducted focus groups and semi-structured interviews with caregivers of children (<18 years) (N = 17) and representatives of community-based organizations (CBOs) which serve children and families (N = 20). Focus group and interview guides were developed based on constructs from the Consolidated Framework for Implementation Research. Data were analyzed using rapid qualitative analysis and matrices were used to identify common themes within and across groups of community members. Desired intervention characteristics included an easy-to-use list of community programs that could be filtered based on caregiver preferences and local community health workers to promote trust and engagement among Black and Hispanic/Latino families. Most community members felt an intervention with these characteristics could be advantageous versus existing alternatives. Key outer setting characteristics which were barriers to family engagement included families' financial insecurity and lack of access to transportation. The CBO implementation climate was supportive but there was concern that the intervention could increase staff workload beyond current capacity. Assessment of implementation determinants during the intervention design phase revealed important considerations for intervention development. Effective implementation of Assets for Health may depend on app design and usability, fostering organizational trust and minimizing the costs and staff workload of caregivers and CBOs, respectively.

The purpose of our work was to design a program to connect families with children to existing health-promoting resources in their communities (i.e., group exercise, food pantries, community gardens). We specifically wanted to capture the needs and preferences of parents with children and community-based organizations and determine the possible barriers to creating this program. Based on prior community listening sessions, the program, called Assets for Health, would consist of a mobile app which lists community resources and a community health worker to help connect families to these resources. We presented the idea for Assets for Health to a diverse group of parents and community-based organizations using focus groups and interviews to carefully capture their thoughts. We then analyzed what was said. This work showed that parents were struggling to find community programs that fit their needs and thought a program like Assets for Health could be helpful. Also organizations were struggling to show families that they could be trusted and that all families were welcome.